ADVANCE NOTICE OF EXCESS CLAIM REPORT Please provide the following information for excess claims which have paid at 15,000 or more. Group Name: Effective Date: Claimant Information Employee Name: DOB: Effective Date: Claimant Name: DOB: Effective Date: Relationship: ME FE MSP FSP MC FC Diagnosis: (Please include ICD9 codes) Amount paid to date: Amount Pending: Reason pending: ***Please contact us if you have large hospital bills, or high dollar RX, or treatments to obtain additional discounts *** Estimate of additional charges: Initial date of treatment: If treatment ongoing, if yes please estimate additional charges: Current Treatment and Prognosis: Please specify if LCM is currently in place: Y or N If yes, please list contact, and phone: If no please specify reason: TPA Name: Address: (Please note this is where reimbursements will be sent) Phone: Submitted By: Date: PLEASE SUBMIT CLAIMS TO: blandis@umexperts.com Underwriting Management Experts 2675191900
2675191900 Aggregate Only Request Form If done electronically it will automatically calculate Total Group Funding: Less Total Paid Claims Less Total Pending and Processed claims: Less Voids Refunds or OOC: Less Previous UME Reimbursements: Total Requested: Please Include with Request: Check Registers Paid Pending Report Aggregate Only Tracking Form Please include any claimant info, including Name, and Diagnosis with more than 15K paid for the current policy period. Please send this to: Claims@umexperts.com
Aggregate Only Tracking Form actors as listed on contract Factors EE ES EC Family 2675191900 Date Group Monthly Funding EE ES EC Fam Actual Funding Needed Medical Claims Paid RX Claims Paid Total Claims Paid Less Any Voids Refunds or OOC Less Previous UMR Reimburse ments Claims Fund Balance Comments Instructions on how to fill out form: You should put sold factors in cells c2c5, this sheet has precalculations populated. And formulas will carry all the way through worksheet. Please submit form monthly whether funds are being requested or not for reporting purposes to:claims@umexperts.com
Bank Account Information for ACH Transfers Please fill out the following information so we can transfer fund requests. Group Name: Effective Date: Bank Account Number: Bank Account Name: ABA Number: Bank Name: Bank Address: Please forward this information to: Claims@umexperts.com Underwriting Management Experts 2675191900
Dear Third Party Administrators: Please find all the forms required for filing Specific, Aggregate, Aggregate Only or Maximum Advantage claims for Underwriting Management Experts. Our phone Directory with contact information. A list of Potential High Dollar or Catastrophic Diagnosis Codes. A 50% Advance Notification. o Also be used to notify of Catastrophic Diagnosis. An Initial Specific Excess Claim Reimbursement Request. (N/A) A Supplemental Specific Excess Claim Reimbursement. (N/A) A Specific Claim Eligibility/Work Status. (N/A) Maximum Advantage/Aggregate Only Tracking Form An Aggregate Excess Insurance Claims Report o This should be submitted on a monthly basis separated by the number of tiers, as specified on the contract terms. Should you have any questions regarding the completion of these forms, please call us at 8553155088. Thank you, Rebecca Landis Chief Claims Officer Underwriting Management Services Underwriting Management Experts
Documentation Requested for Aggregate Only Fund Request(s) When submitting a funding request please include the following: Tracking form Request form Check registers o For first request these should total the paid claims reported o If a supplemental requests this should be from last request to current A pending report this should show total claims that when added to the check registers will match the total claims less any adjustments, out of contract payments, voids or refunds. Also note current monthly premium must be received by UME, and funding in claims account needs to be accounted for. If we do not agree for any reason or payment will be different than requested a written explanation will be sent. Please send this together to the following email address: Claims@umexperts.com Underwriting Management Experts
Corresponding ICD9 Code List 001139 Infectious and Parasitic Diseases 480486 Pneumonia 038038.9 Septicemia 490496 Chronic Obstructive Pulmonary Disease (COPD) 042 Aids/HIV 515 Postinflammatory Pulmonary Fibrosis 07007.9 Viral Hepatitis 518518.9 Pulmonary Collapse and/or Respiratory Failure 140239 Neoplasms 520579 Disease of the Digestive System 140149.9 Malignant Neoplasms of lip, major Salivary Glands, Gum, Mouth,Pharnyx 555555.9 Regional Enteritis (Chron's Disease) 150150.9 Mal Neo Of Esophagus 560560.9 Intestinal Obstruction 151151.9 Mal Neo of Stomach 562 Diverticulitis of Colon 153153.9 Mal Neo of Colon 567567.9 Peritonitis 154154.8 Mal Neo of Rectum 569569.9 Other Disorders of Intestine 155155.2 Mal Neo of Liver 570571.9 Liver Diseases and Cirrhosis 157157.9 Mal Neo of Pancreas 572 Other Sequela of Chronic Liver Disease 161161.9 Mal Neo of Larnyx 573573.9 Other Liver Disorders 162162.9 Mal Neo of Lung 577577.9 Pancrease Diseases 170170.9 Mal Neo of Bone 578578.9 Gastrointestinal Hemorrhage 174174.9 Mal Neo of Female Breast 179182.8 Mal Neo of Uterus or Cervix 580629 Diseases of the Genitourinary System 183183.9 Mal Neo of Ovary 584584.9 Acute Renal Failure 185 Mal Neo of Prostate 585 Chronic Renal Failure 186186.9 Mal Neo of Testis 586 Renal Failure, Unspecified 188189.9 Mal Neo of Brain 588 Disorders Resulting from Impaired Renal Function 191191.9 Mal Neo of Bladder, Kidney, Urinary 592 Calculus of Kidney & Ureter 192192.9 Mal Neo of Nervous System 194194.9 Mal Neo of Endocrine Glands 630677 Complications of Pregnancy, Childbirth 195195.8 Mal Neo of Oth. IllDefined Sites 641 Placenta Previa 196196.9 Secondary Mal Neo Lymph Nodes 642642.9 Eclampsia, Pre Eclampsia 197197.8 Secondary Mal NeoResp & Digestive Systems 644644.9 Premature Labor 198198.89 Secondary Mal Neo Oth Spec Sites 648 Gestational Diabetes 200208.9 Lymphoma and/or Leukemia 651 Multiple Gestation 235 Neoplasm of Uncertain Behavior 654 Abnormality of Organs and Soft Tissue, of Pelvis 239.2 Neoplasm of Uncertain NatureBone, Skin 2675191900 460519 Diseases of the Respiratory System 710739 Diseases of the Musculoskeletal System and Connective Tissue 240279 Endocrine, Nutritional, Metabolic, Immunity 715715.9 Osteoartrhosis 250250.90 Diabetes 721 Lumbosacrel Spondylosis 277 Cystic Fibrosis 722722.9 Intervertibral Disc Disorders 278 Obesity/Hyperliment 730730.9 Osteomyelitis and/or Periostitis 737 Kyphoscoliosis and Scoliosis 280289 Diseases of the Blood and BloodForming Organs 282.6 SickleCell Anemia 740759 Congenital Anomalies 284.9 Aplastic Anemia NOS 747 Aortic Atresia/Stenosis 286286.9 Coagulation Defects and/or Hemophilia 751 Bilary Atresia 759759.9 Other and Unspecified Congenital Anomalies 320389 Diseases of the Nervous System and Sense Organs 330 Cerebral Degenerations 760779 Conditions Originating in the Perinatal Period 344344.9 Quadriplegia and Quadriparesis 765 Prematurity 331331.9 Reye's Syndrome 769 Respiratory Distress Syndrome 344.1 Paraplegia 770770.9 Other Respiratory Conditions in Newborn 348348.9 Encephalopathy 357358 Neuropathy/Mysathenia Gravis 780799 Symptoms, Signs, and IllDefined Conditions 785785.9 Symptoms Involving Cardiovascular System 786786.9 Chest Pain 390459 Diseases of the Circulatory System 410410.9 Acute Myocardia Infarction 800999 Injury and Poisoning 411411.89 Acute and Subacute Ischemic Heart Disease 800804.9 Fracture of Skull 414414.5 Coronary Atherosclerosis (ASHD) 805805.9 Fracture of Vertibral Column 415415.9 Acute Pulmonary Heart Disease 806806.9 Fracture of Vertibral Column with Spinal Cord Inury 416416.9 Chronic Pulmonary Heart Disease 828 Multiple Fractures 417 Aneurysm of Pulmonary Artery 853854 Intracranial injury 421421.9 Acute and Subacute Endocarditis 869 Internal Injury 424424.9 Valve Disorder 887 Traumatic Amputation of Arm and Hand 425425.9 Cardiomyopathy 897 Tramatic Amputation of Leg 426426.9 Conduction Disorders 949949.9 Burns 427427.9 Cardiac Dysrhythmias 952952.9 Spinal Cord Injury 428428.9 Heart Failure 996997 Complications Peculiar to Certain Specified Conditions 430431 Subarachnoid/Intracerebral Hemorrhage 434.9 Occlusion of Cerebral Arteries V23 Supervision of High Risk Pregnancy 436 Acute Cerebrovascular Accident (CVA) V42V58.9 Transplants 440441.9 Atherosclerosis/ Aortic Aneurysm
Lisa Schneider Principal LSCHNEIDER@UMEXPERTS.COM Robert Glorioso Executive Assistant RGLORIOSO@UMEXPERTS.COM Amy Clark Director of Operations ACLARK@UMEXPERTS.COM Samantha Gallagher Chief Underwriting Officer SGALLAGHER@UMEXPERTS.COM Keith Peterson Senior VP of Underwriting KPETERSON@UMEXPERTS.COM Kim Schmidt Senior VP of Underwriting KSCHMIDT@UMEXPERTS.COM Megan Barnes Underwriter MBARNES@UMEXPERTS.COM Kathryn Lesoken Underwriter KLESOKEN@UMEXPERTS.COM Michelle Golembiewski UW Coordinator MGOLEMBIEWSKI@UMEXPERTS.COM Shannon Monaco UW Coordinator SMONACO@UMEXPERTS.COM Donna Yaun Comptroller DYAUN@UMEXPERTS.COM Christine Derstine Director of Compliance CDERSTINE@UMEXPERTS.COM Rebecca Landis Chief Claims Officer BLANDIS@UMEXPERTS.COM Niambi Burton Senior VP of Claims NBURTON@UMEXPERTS.COM Kim Derstine Claims Auditor KDERSTINE@UMEXPERTS.COM UNDERWRITING MANAGEMENT EXPERTS 642 COWPATH RD #196 LANSDALE, PA 19446 2675191900 WEB: WWW.UMEXPERTS.COM (We are working on the website now and anticipate its launch within 3 weeks)